health care financing: recent changes and challenges for ... · - cpt health care professionals...

Health Care Financing: Recent Changes and Challenges for the FutureStephen R. Gillaspy, PhDSenior Director, Health Care Financing

Office of Health Care Financing

P r a c t i c e L e a d e r s h i p C o n f e r e n c e – M a r c h 2 0 2 0

- Describe the CPT® code development and valuation process.

- Discuss current reimbursement challenges for psychologists participating in Medicare, Medicaid programs, and private insurance.

- Explain state and federal advocacy plans and initiatives to improve reimbursement for psychologists.

Overview

2© 2020 APA Services, Inc. Copyright © 2019 by the American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

- Connect reimbursement strategies to clinical and operational models.

- AMA CPT®/RUC strategies need to be proactive:- Partner with medical groups for alternative payment models and new CPT codes.- Develop payment policy guides.

- Develop robust & nimble org structure and infrastructure.- Increase and enhance member communication and education. - Advocate beyond AMA CPT/RUC and Medicare, to also include

Medicaid and commercial payors.

CONCLUSION: APA truly leads and is perceived as THE leader in coding, billing, and reimbursement strategy for the profession.

Proactive Steps

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- Lead APA’s advocacy within the American Medical Association’s (AMA) CPT® Editorial Panel and Specialty Society RVS Update Committee (RUC) processes.

- Develop strategy and lead advocacy initiatives related to financing for psychology practices in the United States.

- Work within policy and advocacy arenas to increase the influence, visibility, and value of psychology within the health care system.

Office of Health Care Financing (OHCF) Priorities


- Collaboration- Within APA

› Advocacy › Legal and Regulatory Affairs› Communications› Practice Research & Policy

- STATE ASSOCIATIONS- Divisions

- Outside of APA› Federal › State Medicaid› Stakeholder Groups› Private Payors› Other Specialty Societies

OHCF Priorities


CPT® Code Development and Valuation Process


- 2019 Psychological and Neuropsychological Testing Codes

- 2020 Health Behavior Assessment and Intervention (HBAI) Codes

- 2020 Cognitive Function Intervention Codes

- 2020 Digital Assessment and Management (e-Visit) Codes

Recent CPT® Coding Changes


- The AMA established and oversees the Committees responsible for the development and valuation of CPT codes

- The CPT Editorial Panel maintains Current Procedural Terminology (CPT®).

- The RUC makes recommendations to the Centers for Medicare and Medicaid Services (CMS) on resources required to provide health care services and relative values assigned to new/revised codes.

CPT® Codes – The AMA & CMS


- While the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that private payers use current CPT® codes, reimbursement values are applicable only to services reported to Medicare through any of its regional carriers. Private payers may set their own reimbursement values.

HIPAA & Reimbursement

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- CPT Editorial Panel Process- Application- Presentation- New/Revised Code Recommendations to RUC

- RUC Process - Survey- Presentation- Code Valuation Recommendations to CMS

- CMS Process- Review of Recommendations- Proposed Rule- Final Rule

The CPT® Code Development & Valuation Process


- AMA House of Delegates- 122 Medical Specialties

- CPT Health Care Professionals Advisory Committee (HCPAC)- 15 Allied Health Societies

- CPT Editorial Panel- 17 Voting Members

› 13 Appointed by AMA Board› 2 from BC/BS Assn, AHIP, AHA, CMS› 2 Voted on by HCPAC

• Psychologist (AP), until June 2016, now Optometrist• Occupational Therapist

CPT ® Editorial Panel Composition


- AMA/Specialty Society RVS Update Committee (RUC)- 31 Voting Members

› 21 of its 31 members appointed by major national medical specialty societies

• 4 Rotating Seats – 1 primary care, 2 internal medicine subspecialty, 1 other• 6 remaining seats – RUC Chair, RUC HCPAC Co-Chair, Chair of Practice

Expense Review Committee & representatives from AMA, CPT® Editorial Panel and AOA

• AMA Board of Trustees selects RUC Chair & AMA representative

- RUC Health Care Professionals Advisory Committee (HCPAC)- 12 limited license practitioners and allied health professionals- 3 RUC members – Representatives from RUC, AMA, & AMA Alternate

RUC Panel Composition


- American Speech-Language-Hearing Association- American Podiatric Medical Association - American Optometric Association- American Chiropractic Association - American Occupational Therapy Association- American Academy of Physician Assistants- American Academy of Audiology- American Psychological Association- American Physical Therapy Association - American Nurses Association- Academy of Nutrition and Dietetics- National Association of Social Workers

*****“…Physician and other qualified healthcare provider…”

RUC Health Care Professional Advisory Committee (HCPAC)


14© APA Services, Inc. Good Practice, Summer 2019

- Three (3) Components of the TOTAL Relative Value Unit (RVU)- Work RVU (wRVU) + - Practice Expense (PE) RVU + - Professional Liability Insurance (PLI) RVU

- Must have Compelling Evidence for Value Increases

- Zero Sum Game = Winners and Losers- Projected 7% decrease in 2021 as an example

Code Values - Important Facts


Current Reimbursement Challenges for Psychologists

Participating in Medicare, Medicaid Programs,

and Private Insurance


- 7% Projected reduction in Medicare reimbursement for 2021

- Practice Expense (PE)

- Medicare Advantage

- Access to CPT® codes

Medicare


- Variation in service/CPT ® code coverage- HBAI codes- Screening codes- Brief intervention codes

- Utilization limitations and variations- Variation in populations covered- Reimbursement rates- Psychiatric Collaborative Care Model (CoCM)

Medicaid & Private Payors


State and Federal Advocacy Plans and Initiatives to

Improve Reimbursement for Psychologists


- 2019- APA

› Official Response› 6,000+ member comments to CMS

- Coalition› Letter to CMS

- 2020- APA

› Engaging CMS- Coalition

› In-Person Meeting with CMS › Letter signed by 99 members of the US House of Representatives› Letter to CMS

7% Projected Reduction in Medicare Reimbursement for 2021

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- Code development (new and revised)

- Practice Expense (PE)

- Alternative Payment Models (APMs)

- Reimbursement for existing CPT® codes

Medicare Strategies


- 99406; Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

- 99407; Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

- 99408; Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

- 99409; Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes

- 99355; Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes

Access to Existing CPT® Codes


- HBAI Code Resource

- Medicaid CPT® Code / Coverage Review

- Model Codes and Utilization

Medicaid & Private Payors


- State Psychiatric Associations proposing legislation

- Alternative model legislation language- Blended model- Psychologist direct care and can serve as the consultant- New (4th) CPT® code- Co-pays

Psychiatric Collaborative Care Model (CoCM)

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- Goal: Access to state level data critical to advocating for improved health care financing at both the state and federal level.

- Areas:- Medicaid- Major payors- Licensure

› Technicians• Psychological & Neuropsychological Testing• ABA Services

State Profiles

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- OHCF Committees- Coding Committee- Testing Advisory Group- Health Behavior Advisory Group

› Representation from: • 9 key APA Divisions and Sections• APA Legal & Regulatory Affairs and Communications Staff

- Member Education- Website & Resources- APA Publications - Consultation

New Activities

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Health Care Financing Advisory Group

Gordon I. Herz, PhDIndependent Practice

Beth Rom- Rymer, PhDIndependent Practice

Monica Kurylo, PhD, ABPPIntegrated Care

Martyn Whittingham, PhDGroup Services

© 2020 APA Services, Inc. Copyright © 2019 by the American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.


Jennifer M. Morgan, PsyDNeuropsychological Testing

Justin Barry, PsyDPsychological Testing

ECP

Sean Woodland, PhDPsychotherapy

ECP

Jamil A. Ashmore, PhD, ABPPHospital Practice



Daniel Holland, PhD, MPHCommercial Payer

Lara Sheehi, PsyDMedicaid

ECP

Antonio Puente, PhDMedicare

Previous CPT Panel Member

Neil Pliskin, PhDMedicare

APA CPT Advisor


- Be Part of the Process!- For example, carefully complete RUC Surveys when requested

- APA Membership

- Collaborate

- State Profiles

What Can You Do To Help?


OHCF Staff

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Meghann Dugan-HaasCoding & Payment Policy Officer

Towhanna BostonAdministrative Coordinator


OHCF Staff

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Toni Vincent, MPH, PMPDirector of Operations

Diane Pedulla, JDDirector, Regulatory Affairs


Questions & Answers


- APA Office of Health Care Financing

- Towhanna Boston via email: [email protected]

For Additional Information


health care financing: recent changes and challenges for ... · - cpt health care professionals...

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